Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...
When do you treat heterotopic ossification with radiation pre-operatively?
Can pre-op radiation be delivered more than 24 hours before surgery?No — this is not recommended and is generally ineffective.Why timing matters (biologic rationale):HO formation is driven by pluripotent mesenchymal progenitor cells that are recruited and activated by: Initial trauma Surgical manipu...
Would you offer additional radiation in a young patient with T4N1 rectal cancer, s/p TNT and pelvic exenteration with a positive deep margin without gross disease seen on post-operative imaging?
This is a very difficult decision. Although somewhat arbitrary, it is considered desirable to have at least a 6-month interval, preferably a year, before considering re-irradiation. For a patient who had surgery following TNT, the interval since the first course of radiation is presumably only a few...
How would you manage T3N0M0 sarcomatoid carcinoma of the prostate with adenosquamous differentiation s/p prostatectomy?
Sarcomatoid prostate cancer is an aggressive histological subtype. It may be locally aggressive, and post-operative PSA monitoring may be less helpful for this histologic subtype, which interferes with the usual trigger for initiation of salvage RT (Grignon, PMID 14976541). Despite the lack of high-...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
I would reverse the question order. For node-positive disease, I start ADT once staging imaging is complete. If logistically practical (as with high-risk localized), I often perform the simulation and start ADT at the same time, then start RT without a neoadjuvant period. Evidence for neoadjuvant AD...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
What is your approach to women with breast cancer who opts for a staged approach with up-front lumpectomy and SLN biopsy (pN-) when there are indications for adjuvant radiation therapy but she plans for a later mastectomy (=>6 months)?
That is not a common approach I have seen, and I would question the rationale of putting a patient through two surgeries when one can be done and forgo RT. If pN0, it would depend on what significant delay is, and I would extensively counsel the patient on recurrence risk should they end up forgoing...
How would you treat a patient with basal cell carcinoma of the medial canthus, with ultimately negative margins after Moh’s surgery, if tumor was “peeled off bone?”
I would treat this patient based on a conversation with the dermatologist, not the PA or other assistant. I'd tell the office that I need the dermatologist to give me 15 minutes and to have all the slides ready for review of what was actually removed, as the periosteum is a good barrier. I reckon th...
When do you prefer pre-operative SRS over post-operative SRS for brain metastases?
For patients with brain metastases that benefit from resection, our approach is to always treat pre-operatively unless the patient requires immediate surgical intervention. Pre-operative SRS has several advantages including clear target delineation. Post-op SRS has best results with expanded volumes...